Provider Demographics
NPI:1417596925
Name:BOLDEN, MACKENZIE M (MS)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:M
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6509 SE CARLTON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-6627
Mailing Address - Country:US
Mailing Address - Phone:509-947-8327
Mailing Address - Fax:
Practice Address - Street 1:10000 NE 7TH AVE STE 403
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685-4548
Practice Address - Country:US
Practice Address - Phone:360-952-3070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-31
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61515373101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor